Have severe COPD? Learn how to manage your symptoms.

Acetylcysteine

Pronunciation

Class: Antidotes
VA Class: RE400
CAS Number: 616-91-1
Brands: Acetadote, Mucomyst

Introduction

Antidote for acetaminophen overdosage; mucolytic agent and sulfhydryl donor.102 103 104 108

Uses for Acetylcysteine

Antidote for Acetaminophen Overdosage

Treatment of acetaminophen overdosage.102 103 104 108 Optimal if given within 8 hours of acetaminophen ingestion;109 may be effective when given ≥24 hours after ingestion.105 106

Prevention of Nephropathy Associated with Radiographic Contrast Media

Has been used to prevent radiographic contrast media-induced nephropathy.100 101 110 111 112 113 114 116 117 Efficacy for this indication not established; additional study needed.110 115 117

Slideshow: Aging Issues: 12 of the Most Common Health Concerns Affecting Seniors

Mucolytic Uses

Adjunctive treatment for patients with abnormal, viscid, or inspissated mucous secretions associated with conditions such as acute and chronic bronchopulmonary disorders (e.g., pneumonia, bronchitis, emphysema, tracheobronchitis, chronic asthmatic bronchitis, tuberculosis, bronchiectasis, primary amyloidosis of the lung); atelectasis caused by mucus obstruction; pulmonary complications of cystic fibrosis; pulmonary complications of thoracic and cardiovascular surgery; and post-traumatic chest conditions.102 103 104

Used during anesthesia and in the preparation of patients for bronchograms, bronchospirometry, bronchial wedge catheterization, and other diagnostic bronchial studies.102 103 104

Tracheostomy care.102 103 104

Acetylcysteine Dosage and Administration

General

  • Determine plasma or serum acetaminophen concentrations as soon as possible (but no sooner than 4 hours) after ingestion.107 May be appropriate to obtain an additional sample at 4–6 hours after initial sample if extended-release acetaminophen preparation was ingested.107

  • Use plasma or serum acetaminophen concentrations in conjunction with a nomogram to estimate potential for hepatotoxicity and necessity of acetylcysteine therapy.105 107

  • Full course of acetylcysteine therapy indicated if initial plasma or serum acetaminophen concentrations fall on or above the dashed line on the nomogram.105 (See nomogram.)106 107

  • Assistance available from a regional poison center at 800-222-1222 or an assistance line for acetaminophen overdosage at 800-525-6115.108

Nomogram relating plasma or serum acetaminophen concentration and probability of hepatotoxicity at varying intervals following ingestion of a single toxic dose of acetaminophen. Modified from Rumack BH, Matthew H. Acetaminophen poisoning and toxicity. Pediatrics. 1975; 55:871-6. American Academy of Pediatrics 1975. And from Rumack BH et al. Acetaminophen overdose. Arch Intern Med. 1981; 141:380-5. American Medical Association.

Multiple Supratherapeutic Acetaminophen Doses

  • Guidelines for the treatment of ingestions involving multiple, higher-than-recommended acetaminophen doses over an extended period of time currently are not available.118 Plasma AST/ALT concentrations and plasma or serum acetaminophen concentrations have been used to estimate potential for hepatotoxicity and necessity of acetylcysteine therapy.108 118

  • Assistance available from a regional poison center at 800-222-1222 or an assistance line for acetaminophen overdosage at 800-525-6115.108

Administration

Administer orally or by IV infusion as an antidote for acetaminophen overdosage; administer by oral inhalation or intracheal instillation for mucolytic uses.102 103 104 108

Has been administered orally100 110 117 or IV110 117 for prevention of radiographic contrast media-induced nephropathy.

Oral Administration

Usually administered as a 5% solution.102 103 104 Dilute 20% solution 1:3 with diet soft drink.102 103 104

Initiate antiemetic therapy or administer via duodenal tube if persistently unable to retain orally administered drug.107

NG Tube

Administer as 5% solution; may use water as the diluent.102 103 104

IV Administration

For solution and drug compatibility information, see Compatibility under Stability.

Administer as a loading dose, followed by a first maintenance dose, then a second maintenance dose.108

Injection concentrate must be diluted prior to IV administration.108

Dilution

Dilute dose with an appropriate volume of 5% dextrose injection (see Table 1).108

Adjust total volume for patients who weigh <40 kg (see Table 1) and for those requiring fluid restriction.108

Table 1. Recommended Volumes of 5% Dextrose Injection for Dilution of IV Acetylcysteine Doses

 

Volume of Diluent for Indicated Dose

Patient’s Weight (kg)

Loading Dose

First Maintenance Dose

Second Maintenance Dose

≥40

200 mL

500 mL

1 L

30

100 mL

250 mL

500 mL

25

100 mL

250 mL

500 mL

20

60 mL

140 mL

280 mL

15

45 mL

105 ml

210 mL

10

30 mL

70 ml

140 mL

Rate of Administration

Loading dose: Infuse over 60 minutes.108 109

First maintenance dose: Infuse over 4 hours.108

Second maintenance dose: Infuse over 16 hours.108

Oral Inhalation and Intratracheal Instillation

For drug compatibility information, see Compatibility under Stability.

Use 20% acetylcysteine solution undiluted or dilute with 0.9% sodium chloride injection or inhalation solution or sterile water for injection or inhalation.102 103 104

May use 10% acetylcysteine solution undiluted.102 103 104

Dosage

Available as acetylcysteine and acetylcysteine sodium; dosage expressed in terms of acetylcysteine.102 103 103 108

Pediatric Patients

Antidote for Acetaminophen Overdosage
Oral

Loading dose: 140 mg/kg, administered as soon as possible.102 103 104 Maintenance dosage, if indicated: 70 mg/kg every 4 hours for 17 doses.102 103 104

If patient vomits a loading or maintenance dose within 1 hour of administration, repeat the dose.107

IV

Loading dose: 150 mg/kg, administered as soon as possible.107 108

First maintenance dose: 50 mg/kg.107 108

Second maintenance dose: 100 mg/kg.107 108

Mucolytic Uses
Nebulization

Face mask, mouthpiece, or tracheostomy: 3–5 mL of the 20% solution or 6–10 mL of the 10% solution 3 or 4 times daily; alternatively, 1–10 mL of the 20% solution or 2–20 mL of the 10% solution every 2–6 hours.102 103 104

Tent or croupette: Volume of acetylcysteine solution should be sufficient to maintain a very heavy mist in the tent or croupette for the desired period; maintenance of heavy mist may require up to 300 mL of the 10 or 20% solution for a single, continuous treatment.102 103 104 Administer intermittently or for continuous prolonged periods.102 103 104

Direct Instillation

1–2 mL of a 10–20% solution as often as every hour.102 103 104

Intratracheal Instillation

Instillation through a percutaneous intratracheal catheter: 1–2 mL of the 20% solution or 2–4 mL of the 10% solution every 1–4 hours via a syringe attached to the catheter.102 103 104

Instillation through a catheter into the trachea: 2–5 mL of the 20% solution via a syringe attached to the catheter.102 103 104

Diagnostic Bronchial Studies
Nebulization

2 or 3 doses of 1–2 mL of the 20% solution or 2–4 mL of the 10% solution prior to the procedure.102 103 104

Intratracheal Instillation

2 or 3 doses of 1–2 mL of the 20% solution or 2–4 mL of the 10% solution prior to the procedure.102 103 104

Tracheostomy Care
Intratracheal Instillation

1–2 mL of a 10–20% solution into the tracheostomy every 1–4 hours.102 103 104

Adults

Antidote for Acetaminophen Overdosage
Oral

Loading dose: 140 mg/kg, administered as soon as possible.102 103 104 Maintenance dosage, if indicated: 70 mg/kg every 4 hours for 17 doses.102 103 104

If patient vomits a loading or maintenance dose within 1 hour of administration, repeat the dose.107

IV

Loading dose: 150 mg/kg, administered as soon as possible.108

First maintenance dose: 50 mg/kg.108

Second maintenance dose: 100 mg/kg.108

Prevention of Nephropathy Associated with Radiographic Contrast Media
Oral

600 mg twice daily, given the day before and the day of contrast media administration (total of 4 doses), has been used.100 110 117 Other dosage regimens have been investigated.110 117

Mucolytic Uses
Nebulization

Face mask, mouthpiece, tracheostomy: 3–5 mL of the 20% solution or 6–10 mL of the 10% solution 3 or 4 times daily; alternatively, 1–10 mL of the 20% solution or 2–20 mL of the 10% solution every 2–6 hours.102 103 104

Tent or croupette: Volume of acetylcysteine solution should be sufficient to maintain a very heavy mist in the tent or croupette for the desired period; maintenance of heavy mist may require up to 300 mL of the 10 or 20% solution for a single, continuous treatment.102 103 104 Administer intermittently or for continuous prolonged periods.102 103 104

Direct Instillation

1–2 mL of a 10–20% solution as often as every hour.102 103 104

Intratracheal Instillation

Instillation through a percutaneous intratracheal catheter: 1–2 mL of the 20% solution or 2–4 mL of the 10% solution every 1–4 hours via a syringe attached to the catheter.102 103 104

Instillation through a catheter into the trachea: 2–5 mL of the 20% solution via a syringe attached to the catheter.102 103 104

Diagnostic Bronchial Studies
Nebulization

For diagnostic bronchial studies: 2 or 3 doses of 1–2 mL of the 20% solution or 2–4 mL of the 10% solution prior to the procedure.102 103 104

Intratracheal Instillation

For diagnostic bronchial studies: 2 or 3 doses of 1–2 mL of the 20% solution or 2–4 mL of the 10% solution prior to the procedure.102 103 104

Tracheostomy Care
Intratracheal Instillation

1–2 mL of a 10–20% solution into the tracheostomy every 1–4 hours.102 103 104

Special Populations

Hepatic Impairment

Antidote for Acetaminophen Overdosage
IV

Published reports do not indicate that the dose should be reduced in patients with hepatic impairment.108 Data are not available to determine whether dosage adjustment is needed in patients with hepatic cirrhosis.108

Renal Impairment

Antidote for Acetaminophen Overdosage
IV

Data are not available to determine whether dosage adjustment is needed in patients with moderate or severe renal impairment.108

Cautions for Acetylcysteine

Contraindications

  • When administered orally as an antidote, no contraindications.102 103 104

  • For other uses (including IV administration as an antidote), hypersensitivity to acetylcysteine or any ingredient in the formulation.102 103 104 108

Warnings/Precautions

Warnings

Encephalopathy Due to Hepatic Failure

If encephalopathy resulting from hepatic failure occurs during oral acetylcysteine therapy, discontinue the drug to avoid further administration of nitrogenous substances.102 103 104

Respiratory Effects

Volume of liquefied bronchial secretions may increase following oral inhalation or intratracheal instillation; potential for airway occlusion.102 103 104 If cough is inadequate to maintain an open airway, institute mechanical suction or endotracheal aspiration.102 103 104

Observe asthmatic patients closely.102 103 104

If bronchospasm occurs, give a bronchodilator by nebulization.102 103 104 If bronchospasm progresses, discontinue acetylcysteine immediately.102 103 104

When administered IV, caution in patients with asthma or history of bronchospasm.108

Sensitivity Reactions

Anaphylactoid Reactions

Serious anaphylactoid reactions (i.e., acute hypersensitivity reactions such as rash, hypotension, wheezing, dyspnea), including death in a patient with asthma, reported in patients receiving IV acetylcysteine.108

Acute flushing and erythema also reported; these reactions generally occur 30–60 minutes after initiation of the infusion and resolve despite continued infusion.108 Reactions to acetylcysteine that involve symptoms other than flushing and erythema should be considered anaphylactoid reactions and treated as such.108

If an anaphylactoid reaction occurs, temporarily interrupt IV acetylcysteine to administer antihistamines and, in severe reactions, epinephrine.108 Once treatment of the anaphylactoid reaction has been initiated, carefully reinstitute IV acetylcysteine.108 If the anaphylactoid reaction recurs or increases in severity, discontinue IV acetylcysteine and consider alternative management.108

Other Allergic Reactions

Generalized urticaria reported rarely in patients receiving oral acetylcysteine for acetaminophen overdosage.102 103 104 If urticaria or other allergic symptoms occur during oral therapy, discontinue the drug unless it is considered essential and allergic symptoms can be otherwise controlled.102 103 104

Sensitization

Sensitization reported rarely.102 103 104

Major Toxicities

GI Effects

Oral administration may result in vomiting or may aggravate vomiting associated with acetaminophen overdosage.102 103 104

Evaluate patients at risk of gastric hemorrhage (e.g., those with esophageal varices or peptic ulcers) with regard to relative risks of upper GI hemorrhage and acetaminophen-induced hepatotoxicity; provide acetylcysteine treatment accordingly.102 103 104

Specific Populations

Pregnancy

Category B.102 103 104 108

Lactation

Not known whether acetylcysteine is distributed into milk; caution advised.102 103 104 108

Pediatric Use

Efficacy of IV acetylcysteine as an antidote for acetaminophen overdosage appears to be similar to that in adults.108

Geriatric Use

Insufficient experience with IV acetylcysteine in patients ≥65 years of age to determine whether geriatric patients respond differently than younger adults.108

Common Adverse Effects

Oral administration: Nausea, vomiting, other GI symptoms, rash with or without fever.102 103 104

IV administration: Rash, urticaria, pruritus.108

Oral inhalation/intratracheal instillation: Stomatitis, nausea, vomiting, fever, rhinorrhea, drowsiness, clamminess.102 103 104

Interactions for Acetylcysteine

Activated Charcoal

Possible interference with absorption of oral acetylcysteine; 119 however, usual dosage of acetylcysteine is appropriate in patients given activated charcoal (higher dosages not necessary).105 106 107

Acetylcysteine Pharmacokinetics

Absorption

Bioavailability

Absorbed following oral administration, with peak plasma concentrations achieved within 1–2 hours.a 119

Absorbed from the pulmonary epithelium.a

Distribution

Extent

Crosses the placenta following oral or IV administration.108

Plasma Protein Binding

50–83%.108 119

Elimination

Metabolism

Deacetylated in the liver to cysteine.a

Elimination Route

Principally (70%) nonrenal.119

Half-life

6.25 hours after oral administration.119

5.6 hours after IV administration in adults.108

11 hours after IV administration in neonates.108

Special Populations

In patients with hepatic cirrhosis, plasma concentrations following IV administration are threefold higher.108 Half-life increased by 80% in patients with severe liver damage (i.e., alcoholic cirrhosis [Child-Pugh score of 7–13] or primary and/or secondary biliary cirrhosis [Child-Pugh score of 5–7]).108

Stability

Storage

Oral, Oral Inhalation, Intratracheal Instillation

Solution

15–30°C.102 103 104 Use diluted solutions within 1 hour.102 103 104 Store undiluted solution in opened vials in refrigerator; use within 96 hours.102 103 104 Do not store admixtures.102 103 104

Parenteral

Injection Concentrate for IV Infusion

20–25°C.108

Presence of light pink to light purple color in solution does not affect the quality of the product.108

Following dilution with 5% dextrose, stable at controlled room temperature for 24 hours.108

Compatibility

For information on systemic interactions resulting from concomitant use, see Interactions.

Parenteral

Solution Compatibility

Compatible108

Dextrose 5% in water

Sodium chloride 0.45%

Drug Compatibility
Y-Site CompatibilityHID

Incompatible

Cefepime HCl

Ceftazidime

Oral Inhalation, Intratracheal Instillation

Presence of light purple color in solution does not appreciably affect potency.102 103 104 a

Drug Compatibility

Incompatible with oxidizing agents.a

Admixture Compatibility103104

Compatible

Cocaine HCl

Dexamethasone sodium phosphate

Epinephrine HCl

Gentamicin sulfate

Halothane

Isoetharine HCl

Isoproterenol HCl

Lidocaine HCl

Lincomycin HCl

Nitrous oxide

Phenylephrine HCl

Polymyxin B sulfate

Tetracaine HCl

Vancomycin HCl

Incompatible

Amphotericin B

Ampicillin sodium

Erythromycin lactobionate

Actions

  • May protect the liver following acetaminophen overdosage by maintaining or restoring glutathione levels or by acting as an alternate substrate for conjugation with (and detoxification of) a toxic intermediate metabolite of acetaminophen (N-acetyl-p-benzoquinoneimine; NAPQI).102 103 104

  • Thiol-containing antioxidant.100 May act as an oxygen free-radical scavenger to prevent radiographic contrast media-induced renal toxicity;100 also may increase the biologic effects of nitric oxide by combining with the oxide to form S-nitrosothiol, a potent vasodilator.101

  • Reduces viscosity of purulent and nonpurulent pulmonary secretions and facilitates their removal by coughing, postural drainage, or mechanical means.102 103 104 Mucolytic effect depends on the free sulfhydryl group, which appears to reduce disulfide linkages of mucoproteins through an interchange reaction.102 103 104

Advice to Patients

  • Importance of women informing clinicians if they are or plan to become pregnant or plan to breast-feed.102 103 104

  • Importance of informing clinicians of existing or contemplated concomitant therapy, including prescription and OTC drugs.102 103 104

  • Importance of informing patients of other important precautionary information.102 103 104 (See Cautions.)

Preparations

Excipients in commercially available drug preparations may have clinically important effects in some individuals; consult specific product labeling for details.

Acetylcysteine Sodium

Routes

Dosage Forms

Strengths

Brand Names

Manufacturer

Oral Inhalation, Intratracheal Instillation, and Oral

Solution

100 mg (of acetylcysteine) per mL (10%)

Acetylcysteine Sodium Solution

Abbott, American Regent, Bedford, Dey, Mayne, Roxane

Mucomyst

Sandoz

200 mg (of acetylcysteine) per mL (20%)

Acetylcysteine Sodium Solution

Abbott, American Regent, Bedford, Dey, Mayne, Roxane

Mucomyst

Sandoz

Acetylcysteine

Routes

Dosage Forms

Strengths

Brand Names

Manufacturer

Parenteral

For injection concentrate, for IV infusion

200 mg/mL

Acetadote

Cumberland

AHFS DI Essentials. © Copyright, 2004-2014, Selected Revisions September 1, 2007. American Society of Health-System Pharmacists, Inc., 7272 Wisconsin Avenue, Bethesda, Maryland 20814.

† Use is not currently included in the labeling approved by the US Food and Drug Administration.

References

Only references cited for selected revisions after 1984 are available electronically.

100. Tepel M, van der Giet M, Schwarzfeld C et al. Prevention of radiographic-contrast -agent-induced reductions in renal function by acetylcysteine. N Engl J Med. 2000; 343:180-4. [IDIS 449660] [PubMed 10900277]

101. Safirstein R, Andrade L, Vieira JM. Acetylcysteine and nephrotoxic effects of radiographic contrast agents—a new use for an old drug. N Engl J Med. 2000; 343: 210-2. [IDIS 449662] [PubMed 10900284]

102. Roxane Laboratories. Acetylcysteine solution USP prescribing information. Columbus, OH; 2001 Oct.

103. Dey. Acetylcysteine solution USP 10% and 20% prescribing information. Napa, CA; 1999 Nov.

104. Apothecon. Mucomyst (acetylcysteine) prescribing information. Princeton, NJ; 2001 Jan.

105. Acetaminophen (paracetamol). In: Ellenhorn MJ, Schonwald S, Ordog G et al., eds. Ellenhorn’s medical toxicology: diagnosis and treatment of human poisoning. 2nd ed. Baltimore, MD: Williams & Wilkens; 1997:180-95.

106. Zed PJ, Krenzelok EP. Treatment of acetaminophen overdose. Am J Health-Syst Pharm. 1999; 56:1081-93. [IDIS 426020] [PubMed 10385455]

107. Poisindex Managements: Acetaminophen-Acute. 26 Jul 2002. From website.

108. Cumberland Pharmaceuticals. Acetadote (acetylcysteine) injection prescribing information. Nashville, TN; 2006 Feb.

109. N-acetylcysteine. In: Goldfrank LR, Flomenbaum NE, Lewin NA et al., eds. Goldfrank’s Toxicologic Emergencies. 7th ed. McGraw-Hill; 2002:502-6.

110. Pannu N, Wiebe N, Tonelli M et al. Prophylaxis strategies for contrast-induced nephropathy. JAMA. 2006; 295:2765-79. [PubMed 16788132]

111. Coyle LC, Rodriguez A, Jeschke RE et al. Acetylcysteine In Diabetes (AID): a randomized study of acetylcysteine for the prevention of contrast nephropathy in diabetics. Am Heart J. 2006; 151:1032.e9-12.

112. Carbonell N, Blasco M, Sanjuán R et al. Intravenous N-acetylcysteine for preventing contrast-induced nephropathy: A randomised trial. Int J Cardiol. 2007; 115:57-62 (Epub 2006 Jun 30). [PubMed 16814414]

113. Bartholomew BA, Harjai KJ, Dukkipati S et al. Impact of nephropathy after percutaneous coronary intervention and a method for risk stratification. Am J Cardiol. 2004; 93:1515-9. [PubMed 15194023]

114. McCullough PA, Adam A, Becker CR et al. Risk prediction of contrast-induced nephropathy. Am J Cardiol. 2006; 98 (suppl 6A):27K-36K.

115. McCullough PA, Stacul F, Davidson C et al. Overview. Am J Cardiol. 2006; 98 (suppl 6A):2K-4K.

116. Davidson C, Stacul F, McCullough PA et al. Contrast medium use. Am J Cardiol. 2006; 98 (suppl 6A):42K-58K. [PubMed 16949380]

117. Stacul F, Adam A, Becker CR et al. Strategies to reduce the risk of contrast-induced nephropathy. Am J Cardiol. 2006; 98 (suppl 6A):59K-77K.

118. Daly FF, O’Malley GF, Heard K et al. Prospective evaluation of repeated supratherapeutic acetaminophen (paracetamol) ingestion. Ann Emerg Med. 2004; 44:393-400. [PubMed 15459622]

119. Holdiness MR. Clinical pharmacokinetics of N-acetylcysteine. Clin Pharmacokinet. 1991; 20:123-34. [PubMed 2029805]

a. AHFS drug information 2003. McEvoy GK, ed. Acetylcysteine. Bethesda, MD: American Society of Health-System Pharmacists; 2003: page 2582-5.

HID. Trissel LA. Handbook on injectable drugs. 14th ed. Bethesda, MD: American Society of Health-System Pharmacists; 2007:6.

Hide
(web1)